Nokea
The client recently diagnosed with glaucoma tells the nurse, 'I'm having difficulty remembering to insert my eye drops. I don't have any pain or vision changes when I forget them.' Which statement is the best response?
- A. You should be diligent in inserting the eye drops; if not, then you will need surgery.
- B. You wouldn't have pain, but untreated glaucoma will eventually lead to vision loss.
- C. Tell me about your day; planning a time with a daily activity often helps as a reminder.
- D. I know this must be hard for you; not everyone is able to remember everything.
Correct Answer: C
Rationale: This is a broad opening statement and can assist the client to problem-solve an activity that could serve as a reminder to take the eye drops. The other statements are either belittling, partially incorrect, or do not help with adherence.
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The 65-year-old male client who is complaining of blurred vision reports he thinks his glasses need to be cleaned all the time, and he denies any type of eye pain. Which eye disorder should the nurse suspect the client has?
- A. Corneal dystrophy.
- B. Conjunctivitis.
- C. Diabetic retinopathy.
- D. Cataracts.
Correct Answer: D
Rationale: Blurred vision and a sense of dirty glasses without pain suggest cataracts, common in older adults. Corneal dystrophy is rarer, conjunctivitis causes redness, and diabetic retinopathy involves floaters or spots.
An adult man fell off a ladder and hit his head and lost consciousness. After regaining consciousness several minutes later, he was drowsy and had trouble staying awake. He is admitted to the hospital for evaluation. The nursing care plan will most likely include which of the following?
- A. Elevate head of bed 15 to 30 degrees
- B. Encourage fluids to 1000 mL every eight hours
- C. Assist the client to cough and deep breathe every two hours
- D. Perform chest physical therapy every four hours while awake
Correct Answer: A
Rationale: Elevating the head of the bed 15 to 30 degrees promotes gravity drainage of fluid and reduces cerebral edema. Coughing, forcing fluids, and chest physical therapy may increase intracranial pressure and are contraindicated.
A client who is recovering from a spinal cord injury complains of blurred vision and a severe headache. His blood pressure is 210/140. The most appropriate initial action for the nurse to take is to:
- A. check for bladder distention.
- B. place him in the Trendelenburg position.
- C. administer PRN pain medication.
- D. position him on his left side.
Correct Answer: A
Rationale: Symptoms suggest autonomic dysreflexia, often triggered by bladder distention, requiring immediate assessment and intervention.
A 68-year-old woman is brought to the emergency room by ambulance. She was found by her husband slumped in her chair and unresponsive. Tentative diagnosis is cerebrovascular accident (CVA). The physician orders a 15% solution of mannitol IV. The nurse knows that this drug is given for what purpose?
- A. To increase urine output
- B. To dissolve clots
- C. To reduce blood pressure
- D. To decrease muscle spasms
Correct Answer: C
Rationale: Mannitol reduces intracranial pressure and blood pressure by promoting diuresis in CVA patients with cerebral edema.
The client is a 60-year-old man who had a stapedectomy. He is to ambulate for the first time. Which nursing action should be taken?
- A. Encourage him to walk as far as he comfortably can
- B. Suggest that he practice bending and stretching exercises
- C. Walk with him, holding his arm
- D. Tell him to take deep breaths while he is ambulating
Correct Answer: C
Rationale: Walking with the client and holding his arm ensures safety and prevents falls post-stapedectomy.